Proximal tibia metaphyseal fractures present a significant challenge in orthopedic trauma care due to their complex nature and the critical role of the tibia in weight-bearing and knee function. Treatment options aim to restore stability, promote healing, and ensure optimal functional outcomes while minimizing complications. Extra-articular fractures of the proximal tibia are often observed and makeup around 5-11% of all fractures involving the tibia [1]. The occurrence of tibia fractures is growing due to its superficial position and the recent surge in high-speed motor vehicle accidents [2,3]. Fractures can be classified into two basic categories: high-energy fractures and low-energy fractures. Metaphyseal fractures of the proximal tibia typically result from direct bending stresses exerted on the upper leg area. Possible treatments for metaphyseal tibial fractures encompass intramedullary interlocking nailing, plate osteosynthesis, external fixator application, and conservative therapy. Each therapy modality has its distinct advantages and disadvantages. Among the various treatment modalities, bridge plating and hybrid external fixation are commonly employed techniques. Bridge plating involves the use of internal plates to stabilize the fracture, offering the potential for better anatomical alignment and earlier mobilization. Bridge plating is an effective method for treating extra-articular proximal tibia fractures, as it successfully restores the bone's anatomical structure [4]. However, plating necessitates the exposure of the bone surface and involves extensive dissection of the soft tissue. As a result, it carries the potential risks of bleeding, infection, difficulties in soft-tissue healing, and complications related to the hardware used. Additionally, plating also damages the periosteum, which plays a crucial role in supplying blood to the fractured area [5]. Hybrid external fixation, on the other hand, combines elements of both external and internal fixation, providing a versatile approach particularly useful in cases with severe soft tissue damage. A hybrid external fixator (HEF) can effectively address issues associated with soft-tissue dissection and healing, but it does come with the potential dangers of malunion, non-union, and pin-tract infections. Another significant constraint of external fixators is the patient's adherence to using the device and properly caring for the pin sites daily. The purpose of this study was to assess the occurrence of complications after surgery, as well as the clinical and functional outcomes, in patients with proximal tibia metaphyseal fractures who were treated with either bridge plating or hybrid external fixation. The Knee Society Score (KSS) was employed to evaluate functional results, encompassing pain, range of motion, stability, alignment, and extension lag as parameters [6].

This prospective randomized study was conducted on 46 adult patients diagnosed with proximal tibia metaphyseal fracture at the Department of Orthopaedics, Darbhanga Medical College and Hospital, Darbhanga, Bihar (India). All patients presenting to the orthopedic outpatient department or emergency department with proximal tibia metaphyseal fractures (closed or open up to Gustilo-Anderson grade III-B), who were over 18 years of age and consented to participate in the study, were included. Patients with proximal tibia fractures associated with a neurovascular deficit in the injured limb (Gustilo-Anderson grade III-C), pathological fractures, or any other associated bony injuries in the same limb were excluded [7]. Upon presentation, patients were screened for other systemic injuries due to their association with high-velocity trauma. Any neurovascular deficits were noted and addressed. Gentle manipulation was performed to achieve a gross reduction of the fracture segment, followed by the application of an above-knee support slab. True anteroposterior and lateral radiographs were taken. A detailed history of the injury, including the mode and severity, was documented. Informed and written consent was obtained from all willing participants in their native language, following the guidelines of the institutional ethical committee. All fractures were classified using the Orthopaedic Trauma Association (OTA) classification [8]. Based on the inclusion and exclusion criteria, 46 patients were enrolled in this study and randomly divided into two groups, A and B, each consisting of 23 patients, using a single-blind method. Group A patients underwent internal fixation with bridge plating using a minimally invasive percutaneous plate osteosynthesis (MIPPO) technique with a 3.5 mm locking compression plate (LCP) of the proximal tibia via an anterolateral approach. Group B patients received fixation with a hybrid external fixator (HEF), involving the insertion of beaded olive wires through safe zones of the proximal tibia, connected to a semi-circular frame, and tensioned using a tensioner. Two or three Schanz screws were inserted into the tibial diaphysis and connected with a tubular rod to each other and the semi-circular ring to complete the construct.

In the postoperative period, static quadriceps and ankle pump exercises were initiated on the same or the next day after surgery. Knee range-of-motion exercises, both active and passive, were started as soon as the pain subsided and the patient felt comfortable, typically within two to three days post-surgery. In the plating group, the surgical wound was inspected and dressed on the third postoperative day, while in the HEF group, daily pin-tract dressings were done. Patients were discharged on the fifth to seventh postoperative day, with antibiotics and analgesics prescribed as needed. Sutures were removed on the 12th to 14th postoperative day. Regular follow-ups were conducted during the second week, sixth week, third month, and sixth-month post-surgery. At each follow-up visit, radiographs were taken, and patients were clinically assessed for pain or other complaints, with functional outcomes evaluated according to the Knee Society Score (KSS) [6].

Statistical Analysis: The collected data was organized into a table using Microsoft Excel 2019. Subsequently, the data was transferred to GraphPad version 8.4.3 for further statistical analysis. The student’s t-test or χ2 test was used to evaluate the differences between the groups. A p-value of less than 0.05 was taken as a measure of significance.

We observed that the average age of patients in the bridge plating group was 45.83 years, with a standard deviation of 16.86 years. In the hybrid external fixator group, the average age was slightly lower at 41.34 years, with a standard deviation of 17.45 years. This difference in age between the two groups was not statistically significant (p > 0.005). In terms of gender distribution, the bridge plating group consisted of 20 males and 3 females, while the hybrid external fixator group had 21 males and 2 females. The difference in gender distribution between the groups was also not statistically significant (p > 0.005). Regarding the side of the body affected by the fractures, 14 patients in the bridge plating group had right-sided involvement, and 9 had left-sided involvement. In the hybrid external fixator group, 15 patients had right-sided involvement, and 8 had left-sided involvement. Again, there was no significant difference between the two groups in terms of which side was involved (p > 0.005) [Table 1].

Table 1: Showing the comparison of baseline demographic and clinical characteristics of the study population

In our study, the mechanism of injury varied slightly between the two groups. In the bridge plating group, 86.95% of the injuries were due to road traffic accidents, while in the hybrid external fixator group, this figure was slightly higher at 91.30%. The remaining injuries in the bridge plating group included 4.35% from being hit by an animal, 4.35% from a fall on a heavy object, and 4.35% from a fall from a height. In the hybrid external fixator group, 4.35% of injuries were due to a fall of a heavy object and 4.35% from a fall from height. These differences in the mechanism of injury were not statistically significant (p > 0.005). When classified according to the Orthopaedic Trauma Association, 69.57% of fractures in the bridge plating group were type 41A2, compared to 56.52% in the hybrid external fixator group. For type 41A3 fractures, the bridge plating group had 30.43% while the hybrid external fixator group had a higher proportion at 43.48%. These differences were also not statistically significant (p > 0.005). Regarding the type of fracture, 8.70% of the fractures in the bridge plating group were open, compared to 21.74% in the hybrid external fixator group. Conversely, 91.30% of fractures in the bridge plating group were closed, compared to 78.26% in the hybrid external fixator group. These differences were not statistically significant either (p > 0.005) [Table 2].

Table 2: Showing the comparison of the mechanism of injury and fracture-related variables.

In our study, the mean surgery time for patients in the bridge plating group was 71.63 minutes, with a standard deviation of 8.45 minutes. In contrast, the mean surgery time for the hybrid external fixator group was significantly shorter, averaging 58.63 minutes with a standard deviation of 8.34 minutes (p < 0.005). The average hospital stay was similar for both groups, with the bridge plating group staying an average of 5.12 days (standard deviation of 1.65 days) and the hybrid external fixator group staying 5.42 days (standard deviation of 1.38 days). This difference was not statistically significant (p > 0.005). Regarding mobilization times, the bridge plating group took an average of 7.15 weeks (standard deviation of 1.68 weeks) to begin partial weight bearing, while the hybrid external fixator group took significantly less time, averaging 5.25 weeks (standard deviation of 3.39 weeks) (p < 0.005). For full weight bearing, the bridge plating group averaged 12.28 weeks (standard deviation of 1.98 weeks) compared to 9.65 weeks (standard deviation of 3.28 weeks) in the hybrid external fixator group, with this difference also being statistically significant (p < 0.005). Lastly, extension lag was observed in 2 cases (8.70%) in the bridge plating group and 4 cases (17.39%) in the hybrid external fixator group. This difference was not statistically significant (p > 0.005) [Table 3].

Table 3: Showing the intraoperative and postoperative variables.

In our study, the hybrid external fixator group experienced some complications that were not observed in the bridge plating group. Specifically, 4.35% of patients in the hybrid external fixator group had delayed union, and 17.40% had pin-tract infections. The bridge plating group did not report any cases of these complications. The hybrid external fixator group also had no cases of screw backout, superficial infection, or wound gaping, while these issues were present in 4.35% of patients in the bridge plating group. Overall, a majority of patients in both groups had no complications, with 78.25% in the hybrid external fixator group and 86.95% in the bridge plating group reporting no issues. [Table 4].

Table 4: Showing the comparison of complications between the two groups.

The mean Knee Society Score (KSS) in the hybrid external fixator (HEF) group was 68.56 ± 7.11, whereas in the bridge plating group, it was higher at 75.45 ± 7.82. In the HEF group, 13.04% of patients had excellent outcomes, 30.43% had good outcomes, 43.48% had fair outcomes, and 13.04% had poor outcomes. Conversely, in the bridge plating group, 30.43% of patients had excellent outcomes, 43.48% had good outcomes, 21.74% had fair outcomes, and only 4.35% had poor outcomes.

Fractures of the proximal tibia encompass a range of injuries to the soft tissues and bones, which have the potential to cause long-lasting impairment. Multiple factors contribute to this fracture, however, high-energy trauma remains the predominant cause. The incidence of these fractures is increasing as a result of the rise in motor vehicles, hence it is imperative to appropriately manage any knee injury as delaying treatment may lead to significant morbidity and have a detrimental effect on the patient's quality of life [1]. Inadequate reduction and improper limb alignment have led to unsatisfactory and disappointing results in nonoperative treatment [9-11]. Open reduction and internal fixation with a plate initially seem to be the preferred treatment options as they effectively address the limitations of conservative care. Nevertheless, when dealing with open wounds or severe closed soft-tissue injuries, performing an open operation becomes more challenging, therefore making external fixation the preferred choice. Under the direction of the c-arm, the use of HEF ensures sufficient reduction and fixation, while also minimizing the problems typically associated with open reduction and internal fixation [12,13]. Several studies have indicated that fractures treated with this method have favorable clinical and radiological results [13,14]. While external fixation effectively prevents future soft-tissue damage, it does present potential issues, including pin-tract infections and inadequate patient compliance. This approach minimizes soft-tissue injuries and demonstrates higher union rates [15]. Regardless of the therapeutic strategy employed, it is preferable to achieve anatomic reduction and stable fixation [16]. This study involved two groups of patients with extra-articular proximal tibia metaphyseal fractures. The patients were treated at a single center using either hybrid external fixation or open reduction and internal fixation with bridge plating. Our study primarily included young adults. The average age of the HEF group was 41.34±17.45 years, while the bridge plating group had an average age of 45.83±16.86 years. Duwelius and Connolly [17] found that the average age was 48 years, whereas Porter [18] reported an average age of 47 years, which aligns with the average age observed in our study. The fracture exhibited a male preponderance, with 41 males and five females. In the HEF group, there were 21 males and 2 females. In the plating group, there were 3 females and 20 males. In this study, males were the most impacted, which aligns with the results published by Albuquerque et al. [19], Manidakis et al. [20], and Mehin et al. [21]. There was no notable disparity in the distribution of males and females between the two groups. The bridge plating group in this study comprised 86.95% of patients who had injuries from a road traffic accident, whereas 4.35% were injured by an animal. The HEF group had 91.30% of patients who were wounded in a road traffic accident (RTA). The remaining 4.35% of injuries were caused by a heavy object falling on the leg and falling from a height, respectively. Ashwani et al. observed comparable outcomes, attributing 92% of the cases to road traffic accidents [22]. The mean duration of operation was significantly shorter in the HEF group (58.63±8.34 minutes) compared to the bridge plating group (71.63±8.45 minutes), with a p-value of 0.001. In our study, the duration of hospitalization was longer for patients in the HEF group (5.42 days) compared to patients in the bridge plating group (5.12 days), however, this difference was not statistically significant between the two groups. The Canadian Orthopaedic Trauma Society [23] found similar results. In our study, we observed that in the HEF group, 17.40% of patients experienced a pin-tract infection, which is higher than the rate reported in a study conducted by Babis et al. [24] (9%). Additionally, 4.35% of patients in the HEF group had delayed union. In contrast, in the plating group, 4.35% of patients experienced screw back out, 4.35% had superficial wound infection, and 4.35% had wound gaping. These rates were lower than those reported in the study by Barei et al. [25] (8.4%) and the Canadian Orthopaedic Trauma Society (20%). The number 23. Various problems and rates were observed in both groups. However, it is worth noting that pin-tract infection is a prominent consequence in the HEF group, while superficial wound infection is more common in the plating group. Our comparison analysis revealed that the bridge plating group experienced fewer difficulties compared to the HEF group. The Canadian Orthopaedic Trauma Society conducted randomized controlled research where they found that the average knee range of motion was 109° for plating and 120° for circular external fixators [23]. The average Knee Society Score (KSS) in the hybrid external fixator (HEF) group was 68.56 ± 7.11, but in the bridge plating group, it was higher at 75.45 ± 7.82. Within the HEF group, 13.04% of patients achieved excellent outcomes, 30.43% achieved good outcomes, 43.48% achieved fair outcomes, and 13.04% achieved bad outcomes. In contrast, within the bridge plating group, 30.43% of patients achieved excellent outcomes, 43.48% achieved good outcomes, 21.74% achieved fair outcomes, and a mere 4.35% experienced poor outcomes. Chaix et al. presented similar findings, reporting that surgical intervention resulted in excellent to good outcomes in 86% of the patients [22].

Both bridge plating and hybrid external fixation (HEF) are effective methods for fixing proximal tibia metaphyseal fractures, each with its own advantages and limitations. Our comparative study revealed that HEF offers benefits such as shorter surgery time, minimal soft-tissue dissection, and earlier initiation of partial and full weight bearing due to quicker radiological evidence of callus formation. Conversely, bridge plating demonstrated superior postoperative knee range of motion and slightly better functional outcomes, as measured by the Knee Society Score (KSS). Therefore, while bridge plating may provide better overall results, the choice of treatment should also consider factors such as the type of fracture, degree of comminution, injury type (open or closed), and bone quality, which can influence clinical outcomes.

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